Category Archives: Centers for Medicare and Medicaid Services (“CMS”)

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Congress Repeals Sustainable Growth Rate Formula and Advances Medicare Payment for Quality

On April 14, 2015, Congress ended over a decade of repeated “doc fixes” which temporarily suspended scheduled Medicare provider reimbursement cuts, by passing the Medicare Access and CHIP Reauthorization Act (the “Act”).  If signed by President Obama, the Act would permanently end the Centers for Medicare & Medicaid Services’ (“CMS”) use of the physician payment … Continue Reading

Medicare ACO v. 3.0—More Risk, More Money?

The Centers for Medicare and Medicaid (CMS) announced on March 10, 2015 that it is adding a new Accountable Care Organization (ACO) model to its cadre of innovative models.[1] Titled the “Next Generation ACO Model,” CMS’ new ACO model allows provider groups to assume higher levels of financial risk and reward than currently available under … Continue Reading

Medicare Advantage Insurers May See Positive Growth in 2016 Despite CMS’ 0.95% Payment Rate Cut Announcement

The Centers for Medicare and Medicaid Services (CMS) proposed a 0.95 percent decrease in Medicare Advantage payment rates for 2016 in its Advance Notice and Draft Call Letter released on February 20, 2015.[1] Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Unlike “original Medicare,” in … Continue Reading

CMS’ Proposed Regulations Include Significant Antitrust Implications For Entities Interested In Forming ACOs

The Centers for Medicare & Medicaid Services (CMS) released proposed regulations to clarify and build on current regulatory requirements for Accountable Care Organizations (ACOs) that participate in the Medicare Shared Savings Program (MSSP).  Among the changes is one addressing when an ACO must be formed as an independent legal entity, separate from any of its … Continue Reading

Effects of the New Federal Spending Package on the Health Sector

In mid-December, President Obama signed into law a $1.1 trillion spending bill known as the “Consolidated and Further Continuing Appropriations Act, 2015” or “Cromnibus.”[1] This post explores provisions that relate to the health sector and Affordable Care Act (ACA) implementation.… Continue Reading

CMS Defines “Uninsured” for Medicaid DSH Payments But Leaves Impact on Hospital-Specific Payments Undefined

CMS’ Final Rule, “Medicaid; Disproportionate Share Hospital Payments – Uninsured Definition”, published on December 3, 2014, may offer relief to some hospitals receiving Medicaid disproportionate share hospital (DSH) payments under the Social Security Act.[1] Starting December 31, 2014, the rule’s definition of “uninsured,” used to calculate the hospital-specific limitation on DSH payments, will allow for … Continue Reading

Pioneer ACOs: Slowed Health Spending, Improved Quality and More Drop Outs?

The Centers for Medicare and Medicaid Services (CMS) recently released second year results on its Pioneer Accountable Care Organization (ACO) program. [1] [2]  The Pioneer ACO program is CMS’ ambitious foray into the ACO space and a predecessor to the broader Medicare Shared Savings Program (MSSP) that has resulted in the formation of hundreds of … Continue Reading

Final Meaningful Use Rule: CMS Loosens its Grip

The Centers for Medicare & Medicaid Services (“CMS”) finalized a rule on August 29th which should give providers some breathing room in complying with meaningful use requirements for the Electronic Health Record (“EHR”) Incentive Program (the “Final Rule”).  The EHR Incentive Program was developed by CMS to motivate health care providers to use and implement EHR … Continue Reading

Pennsylvania gets a green light to pursue Medicaid expansion under an alternative model

The Centers for Medicare and Medicaid Services (CMS) has approved Pennsylvania’s demonstration proposal to expand Medicaid to adults with incomes through 133 percent of the federal poverty line. The state is the 28th (including D.C.) to pursue Medicaid expansion, and one of a growing number of states to do so under an alternative model developed … Continue Reading

CMS Care Coordination Payments – A Boon to Doctors and Patients but Patient Participation Will be Essential

As the Affordable Care Act continues to mature, we are seeing new efforts by the Obama administration to incentivize care coordination across a spectrum of services provided to Medicare Fee-for-Service (FFS) patients.  A New York Times article posted on August 16, 2014 reports that starting in January of 2015 Medicare will begin making monthly payments to … Continue Reading

CMS seeks to update payment rates and eligibility certification requirements in proposed rule for Medicare home health services

On July 7, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule updating Medicare’s Home Health Prospective Payment System payment rates for 2015.[1] The rule implements the second phase of a four-year initiative to rebase Medicare home health payments. Specifically, the national, standardized 60-day episode payment amount, the national per-visit rates and … Continue Reading

The Future of DSH Payments?

According to the Centers for Medicare and Medicaid Services (CMS), the federal government disburses $11.5 billion annually in disproportionate-share hospital (DSH) payments to states.  DSH payments are intended to offset the cost of treating the uninsured (uncompensated care) and Medicaid shortfalls in public hospitals.  A recent study published in Health Affairs on the impact of … Continue Reading

Cloudy Skies Ahead for Providers? CMS’ Release of Medicare Billing Data Combined with Physician Payment Sunshine Act Data May Boost Fraud Litigation

In February 2013, we reported (on our Healthcare Law Blog) that the Centers for Medicare and Medicaid Services (CMS) announced the final rule for the Physician Payments Sunshine Act.  In the interest of providing more transparency for patients, the final rule requires pharmaceutical and medical device manufacturers and group purchasing organizations to report payments or … Continue Reading

Quantifying and addressing improper payments for Medicare evaluation and management services

A review of Medicare Part B claims for evaluation and management (E/M) services conducted by the Office of the Inspector General (OIG) has found that the program paid $6.7 billion in improper payments in 2010.[1] This figure represents 21 percent of all E/M payments for the year; E/M payments, generally, accounted for nearly 30 percent … Continue Reading

Proposed modifications to EHR Incentive Programs

Last year, HHS revised policies and definitions surrounding what constitutes certified EHR technology—required for meaningful use incentive program payment eligibility—from the 2011 Edition criteria to the 2014 Edition criteria. Now, CMS has issued a proposed rule in response to hardships expressed by vendors, hospitals and healthcare providers regarding updating their systems per the new standards … Continue Reading

The push for greater transparency in healthcare continues

Recently, CMS released the proposed fiscal year 2015 Inpatient Prospective Payment System (IPPS) rule for inpatient stays in long-term and general acute care hospitals.[1] Included among the regular updates to Medicare payment policies and rates are guidelines for compliance with the Affordable Care Act’s hospital charges transparency requirement.… Continue Reading

Enforcement of the Two-Midnight Rule Delayed Again

Last week President Obama signed into law a measure to extend Medicare physician pay rates for one year and to extend the enforcement delay of the “Two-Midnight” rule through March 2015.  Medicare Recovery Audit Contractors (RACs) are prohibited from auditing inpatient hospital claims for compliance with the rule from October 1, 2013, through March 31, … Continue Reading

New Approaches – and Increasing Oversight – for Medicaid Managed Long Term Services and Support

Approximately one-third of Medicaid spending, $136 billion, is on long-term services and supports (LTSS).  While the majority of Medicaid LTSS takes place in institutional settings, such as nursing facilities and mental health facilities, there is an ongoing emphasis on the role of non-institutional facilities. A growing number of states, from 8 in 2004 to 16 … Continue Reading

A Review of CMS’ Approach to $125 Million Recoupment of Payments to Providers for Services to Incarcerated / Unlawfully Present Beneficiaries

CMS seeks to recover from providers $125 million in alleged overpayments for services to beneficiaries who are belatedly identified as ineligible (incarcerated/unlawfully present). In this post, Sheppard Mullin examines the recovery process CMS has put in place, noting CMS procedural shortcomings and reviewing some substantive defenses available to providers facing such demands.… Continue Reading

CMS Announces Participants in Bundled Payments for Care Improvement Initiative

The Centers for Medicare & Medicaid Services (CMS) recently announced that over 500 organizations will begin participating in the Bundled Payments for Care Improvement initiative. The large number of participating organizations now exceeds the number of Medicare ACOs, and makes the Bundled Payments initiative the largest voluntary Medicare payment innovation program. Participating organizations are located … Continue Reading
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